United States
Department of
Agriculture
Food and
Nutrition
Service
Accommodating Children with
Special Dietary Needs in the
School Nutrition Programs
Guidance for School Food Service Staff
In accordance with Federal law and U.S. Department of Agriculture
policy, this institution is prohibited from discriminating on the basis
of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office
of Civil Rights, Room 326-W, Whitten Building, 1400 Independence
Avenue, SW, Washington, D.C., 20250-9410, or call 202-720-5964
(voice and TDD). USDA is an equal opportunity provider and
employer.
No substantive changes were made to this manual. Minor updates were made and several
obsolete appendices were deleted.
Fall 2001
GUIDANCE FOR ACCOMMODATING CHILDREN
WITH SPECIAL DIETARY NEEDS
IN THE SCHOOL NUTRITION PROGRAMS
TABLE OF CONTENTS
I.
INTRODUCTION
II.
DEFINITIONS OF DISABILITY AND OF OTHER
SPECIAL DIETARY NEEDS
A. Disability………………………………………………...…….3
B. Other Special Dietary Needs……………………………...…...6
III.
SCHOOL ISSUES
A. School Food Service Responsibilities……………..……….…7
B. Funding Sources……………………………………………..10
C. Helpful Resources…………………………………………...14
D. Information Sources…………………………….…………...16
IV.
LEGAL CONCERNS AND LIABILITY IN WORKING
WITH CHILDREN WITH DISABILITIES
A. School Responsibility To Make
Accommodations……………………………………..…….18
B. Personal Responsibility In Cases Of
Negligence…………………………………………….……20
V.
SITUATIONS AND RESPONSES
A. Meals and/or Foods Outside of the Normal
Meal Service………………………………………………..23
B. Special Needs Which May or May Not Involve
Disabilities……………………………………………….....25
C. Responsibilities of Food Service Management
Companies (FSMC) and Other Food
Service Operations………………………………………….27
SITUATIONS AND RESPONSES (continued)
D. Feeding in Separate Facilities – Generally
Not Acceptable……………………………………………...28
E. Temporary Disabilities……………………………………….29
F. Complicated Feedings………………………………………..29
G. School Food Service Account…………………………….…31
H. Documentation…………………….………………..……….32
VI.
SAMPLE DOCUMENTATION FOR SPECIAL
DIETARY NEEDS
A. FIG 1. Eating/Feeding Evaluation.……………………….….34
B. FIG 2. Information Card……………………………………..35
VII.
GLOSSARY………………………………………….………….36
LIST OF APPENDICES
APPENDIX A
FNS Instruction 783-2, Revision 2, Meal Substitutions for Medical or
Other Special Dietary Reasons………………………………………41
U.S. Department of Agriculture Nondiscrimination
Exhibit A - Regulations: 7 CFR Part 15b......................................…….47
APPENDIX B
USDA, Food and Nutrition Service
Regional Contacts Special Nutrition Programs............................……..49
Regional Contacts Civil Rights………………………………………..50
APPENDIX C
Department of Health and Human Services
Regional Contacts.........................................................…………….......51
APPENDIX D
Voluntary and Professional
Health Organizations...............................................…………………..52
GUIDANCE FOR ACCOMMODATING CHILDREN
WITH SPECIAL DIETARY NEEDS
IN THE SCHOOL NUTRITION PROGRAMS
I.
INTRODUCTION
In recent years, we have seen increasing emphasis on the importance of
ensuring that children with disabilities have the same opportunities as
other children to receive an education and education-related benefits, such
as school meals.
Congress first addressed this concern in The Rehabilitation Act of 1973,
which prohibits discrimination against qualified persons with disabilities
in the programs or activities of any agency of the federal government's
executive branch or any organization receiving federal financial
assistance.
Subsequently, Congress passed the Education of the Handicapped Act,
(now, the Individuals with Disabilities Education Act), which requires that
a free and appropriate public education be provided for children with
disabilities, who are aged 3 through 21, and the Americans with
Disabilities Act, a comprehensive law which broadens and extends civil
rights protections for Americans with disabilities.
One effect of these laws has been an increase in the number of children
with disabilities who are being educated in regular school programs. In
some cases, the disability may prevent the child from eating meals
prepared for the general school population.
The U.S. Department of Agriculture's (USDA) nondiscrimination
regulation (7 CFR 15b), as well as the regulations governing the National
School Lunch Program and School Breakfast Program, make it clear that
substitutions to the regular meal must be made for children who are unable
to eat school meals because of their disabilities, when that need is certified
by a licensed physician.
1
In most cases, children with disabilities can be accommodated with little
extra expense or involvement. The nature of the child's disability, the
reason the disability prevents the child from eating the regular school
meal, and the specific substitutions needed must be specified in a
statement signed by a licensed physician. Often, the substitutions can be
made relatively easily. There are situations, however, which may require
additional equipment or specific technical training and expertise. When
these instances occur, it is important that school food service managers
and parent(s) be involved at the outset in preparations for the child's
entrance into the school.
This guidance describes some of the factors which must be considered in
the early phases of planning and suggests ways in which the school food
service can interact with other responsible parties in the school and the
community at large to serve children with disabilities.
The guidance is based on the policy guidelines outlined in the FNS
Instruction 783-2, Revision 2, Meal Substitutions for Medical or Other
Special Dietary Reasons.
Serving children with disabilities presents school food service staff with
new challenges as well as rewards. This guidance presents information on
how to handle situations that may arise and offers advice about such issues
as funding and liability.
The guidance was prepared in consultation with the U.S. Department of
Justice and the U.S. Department of Education and will be periodically
updated to reflect new scientific information or new statutory and program
guidelines.
2
II.
DEFINITIONS OF DISABILITY AND OF OTHER
SPECIAL DIETARY NEEDS
A.
DISABILITY
Rehabilitation Act of 1973 and the Americans with
Disabilities Act
Under Section 504 of the Rehabilitation Act of 1973, and the Americans
with Disabilities Act (ADA) of 1990, a "person with a disability" means
any person who has a physical or mental impairment which substantially
limits one or more major life activities, has a record of such an
impairment, or is regarded as having such an impairment.
The term "physical or mental impairment" includes many diseases and
conditions, a few of which may be:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
orthopedic, visual, speech, and hearing impairments;
cerebral palsy;
epilepsy;
muscular dystrophy;
multiple sclerosis;
cancer;
heart disease;
metabolic diseases, such as diabetes or phenylketonuria (PKU);
food anaphylaxis (severe food allergy);
mental retardation;
emotional illness;
drug addiction and alcoholism;
specific learning disabilities;
HIV disease; and
tuberculosis.
Please refer to the Acts noted above for a more detailed explanation.
Major life activities covered by this definition include caring for one's self,
eating, performing manual tasks, walking, seeing, hearing, speaking,
breathing, learning, and working.
3
Individuals with Disabilities Education Act
The term child with a "disability" under Part B of the Individuals with
Disabilities Education Act (IDEA) means a child evaluated in accordance
with IDEA as having one or more of the recognized thirteen disability
categories and who, by reason thereof, needs special education and related
services.
IDEA recognizes thirteen disability categories which establish a child's
need for special education and related services. These disabilities include:
•
•
•
•
•
•
•
•
•
•
•
•
autism;
deaf-blindness;
deafness or other hearing impairments;
mental retardation;
orthopedic impairments;
other health impairments due to chronic or acute health problems, such
as asthma, diabetes, nephritis, sickle cell anemia, a heart condition,
epilepsy, rheumatic fever, hemophilia, leukemia, lead poisoning,
tuberculosis;
emotional disturbance;
specific learning disabilities;
speech or language impairment;
traumatic brain injury; and
visual impairment; including blindness which adversely affects a
child’s educational performance, and
multiple disabilities.
Attention deficit disorder or attention deficit hyperactivity disorder may
fall under one of the thirteen categories. Classification depends upon the
particular characteristics associated with the disorder and how the
condition manifests itself in the student, which will determine the
category.
The Individualized Education Program or IEP means a written statement
for a child with a disability that is developed, reviewed, and revised in
accordance with the IDEA and its implementing regulations. The IEP is
the cornerstone of the student’s educational program that contains the
program of special education and related services to be provided to a child
with a disability covered under the IDEA.
4
NOTE: Some states supplement the IEP with a written statement
specifically designed to address a student’s nutritional needs. Other states
employ a “Health Care Plan” to address the nutritional needs of their
students. For ease of reference, the term “IEP” is used to reflect the IEP
as well as any written statement designating the required nutrition
services.
When nutrition services are required under a child's IEP, school officials
need to make sure that school food service staff are involved early on in
decisions regarding special meals.
Physician's Statement for Children with Disabilities
USDA regulations 7 CFR Part 15b require substitutions or modifications
in school meals for children whose disabilities restrict their diets. A child
with a disability must be provided substitutions in foods when that need is
supported by a statement signed by a licensed physician. The physician's
statement must identify:
✔
✔
✔
✔
the child's disability;
an explanation of why the disability restricts the child's diet;
the major life activity affected by the disability;
the food or foods to be omitted from the child's diet, and the food
or choice of foods that must be substituted.
In Cases of Food Allergy
Generally, children with food allergies or intolerances do not have a
disability as defined under either Section 504 of the Rehabilitation Act or
Part B of IDEA, and the school food service may, but is not required to,
make food substitutions for them.
However, when in the licensed physician's assessment, food allergies may
result in severe, life-threatening (anaphylactic) reactions, the child's
condition would meet the definition of "disability," and the substitutions
prescribed by the licensed physician must be made.
5
B.
OTHER SPECIAL DIETARY NEEDS
The school food service may make food substitutions, at their discretion,
for individual children who do not have a disability, but who are
medically certified as having a special medical or dietary need.
Such determinations are only made on a case-by-case basis. This
provision covers those children who have food intolerances or allergies
but do not have life-threatening reactions (anaphylactic reactions) when
exposed to the food(s) to which they have problems.
Medical Statement for Children with Special Dietary Needs
Each special dietary request must be supported by a statement, which
explains the food substitution that is requested. It must be signed by a
recognized medical authority.
The medical statement must include:
✔
✔
✔
an identification of the medical or other special dietary condition
which restricts the child's diet;
the food or foods to be omitted from the child's diet; and
the food or choice of foods to be substituted.
6
III.
SCHOOL ISSUES
The school food service, like the other programs in the school, is
responsible for ensuring that its benefits (meals) are made available to all
children, including children with disabilities. This raises questions in a
number of areas:
A.
What are the responsibilities of the school food service?
B.
Where can additional funds be obtained?
C.
Who can provide more information and technical assistance?
A.
SCHOOL FOOD SERVICE RESPONSIBILITIES
✔
School food service staff must make food substitutions or
modifications for students with disabilities.
✔
Substitutions or modifications for children with disabilities must
be based on a prescription written by a licensed physician.
✔
The school food service is encouraged, but not required, to provide
food substitutions or modifications for children without disabilities
with medically certified special dietary needs who are unable to eat
regular meals as prepared.
✔
Substitutions for children without disabilities, with medically
certified special dietary needs must be based on a statement by a
recognized medical authority.
✔
Under no circumstances are school food service staff to revise or
change a diet prescription or medical order.
✔
For USDA’s basic guidelines on meal substitutions and
accessibility, see FNS Instruction 783-2, Revision 2, Meal
Substitutions for Medical or Other Special Dietary Reasons, in
Appendix A.
7
✔
It is important that all recommendations for accommodations or
changes to existing diet orders be documented in writing to protect
the school and minimize misunderstandings. Schools should retain
copies of special, non-meal pattern diets on file for reviews.
✔
The diet orders do not need to be renewed on a yearly basis;
however schools are encouraged to ensure that the diet orders
reflect the current dietary needs of the child.
Providing Special Meals to Children with Disabilities
The school food service is required to offer special meals, at no additional
cost, to children whose disability restricts their diet as defined in USDA's
nondiscrimination regulations, 7 CFR Part 15b.
✔
If a child's IEP includes a nutrition component, the school should
ensure that school food service managers are involved early on in
decisions regarding special meals or modifications.
✔
The school food service is not required to provide meal services to
children with disabilities when the meal service is not normally
available to the general student body, unless a meal service is
required under the child's IEP.
For example, if a school breakfast program is not offered, the school food
service is not required to provide breakfast to the child with a disability,
unless this is specified in the child's IEP.
However, if a student is receiving special education and has an IEP, and
the IEP indicates that the child needs to be served breakfast at school, then
the school is required to provide this meal to the child and may choose to
have the school food service handle the responsibility. This is discussed
in more detail in Section V, under Situation 2.
Menu Modifications for Children with Disabilities
Children with disabilities who require changes to the basic meal (such as
special supplements or substitutions) are required to provide
documentation with accompanying instructions from a licensed physician.
8
This is required to ensure that the modified meal is reimbursable, and to
ensure that any meal modifications meet nutrition standards which are
medically appropriate for the child.
Texture Modifications for Children with Disabilities
For children with disabilities who only require modifications in texture
(such as chopped, ground or pureed foods), a licensed physician's written
instructions indicating the appropriate food texture is recommended, but
not required.
However, the State agency or school food authority may apply stricter
guidelines, and require that the school keep on file a licensed physician's
statement concerning needed modifications in food texture.
✔
In order to minimize the chance of misunderstandings, it is
recommended that the school food service, at a minimum, maintain
written instructions or guidance from a licensed physician
regarding the texture modifications to be made. For children
receiving special education, the texture modification should be
included in the IEP.
✔
School food service staff must follow the instructions that have
been prescribed by the licensed physician.
Serving the Special Dietary Needs of Children Without
Disabilities
Children without disabilities, but with special dietary needs requiring food
substitutions or modifications, may request that the school food service
meet their special nutrition needs.
✔
The school food authority will decide these situations on a caseby-case basis. Documentation with accompanying information
must be provided by a recognized medical authority.
✔
While school food authorities are encouraged to consult with
recognized medical authorities, where appropriate, schools are not
required to make modifications to meals based on food choices of
a family or child regarding a healthful diet.
9
B.
FUNDING SOURCES
Price of Meals
Meals must be served free or at a reduced price (a maximum of 40 cents
for lunch and 30 cents for breakfast) to children who qualify for these
benefits regardless of whether or not they have a disability.
Schools may not charge children with disabilities or with certified special
dietary needs who require food substitutions or modifications more than
they charge other children for program meals or snacks.
Incurring Additional Expenses
In most cases, children with disabilities can be accommodated with little
extra expense or involvement. If additional expenses are incurred in
providing food substitutions or modifications for children with special
needs, generally the school food authority should be able to absorb the
cost of making meal modifications or paying for the services of a
registered dietician.
However, when the school food service has difficulty covering the
additional cost, there are several alternative sources of funding which
school food service managers, school administrators, parents or guardians,
and teachers may consider. These sources include the school district's
general fund and the additional funding sources listed below.
Any additional funding received by school food services for costs incurred
in providing special meals must accrue to the nonprofit school food
service account.
10
POTENTIAL FUNDING SOURCES
Individuals with Disabilities Education Act
The Individuals with Disabilities Education Act (IDEA), through the Part
B Program, provides Federal funds to assist States and school districts in
making a "free appropriate public education" available to eligible
children with specified disabilities residing within the State.
Students with specified physical, mental, emotional or sensory
impairments that need special education and related services are eligible
for services under IDEA, at no cost to parents.
In appropriate situations, nutrition services may be specified as special
education (specially designed instruction) or a related service (support
services required to assist a child with a disability to benefit from special
education).
Services which may be funded through IDEA include: (1) purchase of
special foods, supplements, or feeding equipment; (2) consultation
services of a registered dietitian or nutrition professional; and
(3) assistance of a special education teacher, occupational therapist or
other health professional in feeding the child or developing feeding skills.
Website address: Department of Education/IDEA: http://www.ed.gov,
(scroll down to “Most Requested Items” Disabilities Education (IDEA))
Medicaid
Title XIX of the Social Security Act is an entitlement program which
finances medical services for certain individuals and families with low
income and resources.
Within broad Federal guidelines, a State or territory:
(1) establishes its own eligibility standards; (2) determines the type,
amount, duration, and scope of services; (3) sets the rates of payment for
services; and (4) administers its own program.
11
The Medicaid program, jointly funded by Federal and State governments,
varies considerably from State to State as each State adapts the program to
its own unique environment.
In the case of certain low-income children eligible for Medicaid, Medicaid
may pay for services that are medical and remedial in nature. These
services may include special dietary supplements, eating devices, and
nutritional consultation as medically necessary.
Medicaid reimbursement is paid directly to the provider of services, such
as a physician, pharmacy, medical equipment supplier, clinic, and, in
certain situations, the school food authority and/or school. Questions
regarding provider qualifications should be directed to your State
Medicaid agency.
If you have questions about who has access to Medicaid, how to qualify as
an authorized provider, or what services are covered by Medicaid in your
State, contact your State Medicaid agency.
For information or a referral, check with the Medicaid division, at the
regional office of the Health Care Financing Administration for your
State. (See Appendix C)
Website address: http://www.hcfa.gov/medicaid/.
Early and Periodic Screening, Diagnostic and Treatment
Program
Medicaid's child health program, the Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) Program is a preventive and
comprehensive health care benefit for Medicaid-eligible individuals up to
age 21. EPSDT includes screening for dental, hearing and vision services.
An objective of the EPSDT Program is to detect and treat health problems
and conditions early before they become more complex and costly. The
EPSDT Program allows providers, including schools, to be reimbursed for
preventive and treatment services for Medicaid-eligible children.
Questions regarding EPSDT coverage under Medicaid should be directed
to the State Medicaid agency or to your State EPSDT Coordinator.
Website address: http://www.hcfa.gov/medicaid/EPSDThm.htm
12
Supplemental Security Income
Supplemental Security Income (SSI), under Title V of the Social Security
Act, provides rehabilitative services to children under age 16 who are
receiving benefits under SSI, to the extent that Medicaid does not cover
the service. SSI provides basic income for needy children under age 18
(students under age 22) who are blind or who have a severe disability or
chronic illness.
For information on SSI eligibility, contact your local Social Security
Office or call the Social Security Administration’s toll free telephone
number, 1-800-772-1213, (TTY/TDD, 1-800-325-0778).
Website address: http://www.SSA.gov, and scroll down to
Supplemental Security Income
Medicare
Medicare provides services for children and adults with end-stage renal
(kidney) disease. However, Medicare coverage of nutritional supplies is
generally limited to durable medical equipment such as a feeding pump or
other special (parenteral or enteral) nutritional feeding equipment
necessary for people who cannot be sustained through normal means of
feeding by mouth.
For more information, telephone the toll free Medicare Hotline at, 1-800633-4227 or (TTY/TDD, 1-800-820-1202).
Website address: http://www.medicare.gov
Maternal and Child Health (MCH) Services Block Grants
The Maternal and Child Health Bureau, at the Department of Health and
Human Services, administers Maternal and Child Health Services Block
Grants, authorized under Title V of the Social Security Act. These grants
enable States to assess health needs and provide a wide range of
community-based services for children with special health care needs.
13
State Title V programs work closely with community health centers,
public health clinics, and school health programs. Contact the Regional
MCH Program Consultant for your State, listed in Appendix C, for
information about your State’s Title V program activities.
Community Sources
Parent Teacher Associations (PTA), voluntary health associations, local
civic organizations, and other community-based groups may be able to
assist with the procurement of equipment and provide other support
services. See Appendix D for a partial list of voluntary and professional
health organizations which offer information and support for various
disabilities or special health care needs.
C.
HELPFUL RESOURCES
School food service staff should work closely with the support people who
are familiar with the needs of the child. The child's parents or guardians,
teachers, occupational and physical therapists, special education staff, and
the school nurse are valuable resources.
Local health department, hospital, or medical center registered
dietitians may be able to provide assistance in understanding diet orders,
developing and modifying meal plans and menus, special food item
purchases, and other aspects of feeding children with special needs.
In addition, the following resources may provide technical assistance or
referrals to qualified nutrition and health professionals:
• State Title V Directors, Maternal and Child Health (MCH)
Each State has a Title V director responsible for overseeing State
programs for children with special health care needs. Most States also
have public health nutritionists who are responsible for nutritional services
for these children.
Contact the Regional MCH Program Consultant for your State listed in
Appendix C for information on State Title V program activities or refer to
your State Title V MCH personnel.
14
• Registered Dietitians of the American Dietetic
Association (ADA)
Registered Dietitians (R.D.) can answer questions on special diets and
menu planning to help school food service staff better understand a child’s
special dietary needs. An R.D. may work with the recognized medical
authority and the school food service to help meet a child’s special
nutritional needs and ensure that menus comply with the diet order. These
types of services are allowable program costs.
The ADA's toll free Consumer Nutrition Information/Hotline is
1-800-366-1655 which can provide referrals to qualified R.D.s in your
area as well as daily nutrition messages.
Website address: http://www.eatright.org
• University Affiliated Programs for Developmentally
Disabled (UAP)
UAPs were established to support the independence, productivity, and
community integration of all citizens with developmental disabilities.
Within their States, UAPs serve as links between the academic world and
the delivery of services to persons with developmental disabilities. UAPS
also provide families and individuals with a variety of support services.
For a referral to a UAP in your area, contact the National Office of the
American Association of University Affiliated Programs at (301) 5888252.
Website address: http://www.aauap.org
• Regional Disability and Business Technical Assistance Centers
Ten regional centers are funded by the National Institute on Disability
Rehabilitation and Research of the U.S. Department of Education to
provide information and technical assistance on the Americans with
Disabilities Act (ADA). The Regional ADA Coalition in your area may
also be helpful.
15
Copies of ADA documents, supplied by the Equal Employment
Opportunity Commission and the Department of Justice, may be obtained
at any of the regional centers. These materials are available in standard
print, large print, Braille, on audiocassette and computer disk.
For the telephone number and address of your regional center, call the
ADA Technical Assistance Center’s toll free number:
1-800-949-4ADA.
• Other Health Care and Disability Related Organizations
Appendix D contains a listing of organizations which may offer
assistance regarding children with different health care needs. The
appendix includes such organizations as the American Diabetes
Association, the Food Allergy and Anaphylaxis Network, United Cerebral
Palsy
Association, the Easter Seal Society, and many more.
D.
INFORMATION SOURCES
There are a growing number of excellent information services that can
provide resources and answer your questions about accommodating
children with special dietary needs.
The following are federally funded sources:
• Food and Nutrition Information Center (FNIC).
FNIC is an information center located at USDA’s National Agricultural
Library (NAL). FNIC staff has prepared resource lists on food service
topics that are located on their website. Phone FNIC for more
information. (301) 504-5719, or TTY: (301) 504-6856).
Website address: http://www.nal.usda.gov/fnic.
FNIC’s Healthy School Meals Resource System offers online training
materials and connects with other food service resources.
Website address: http://schoolmeals.nal.usda.gov
16
• National Agriculture Library (NAL)
NAL has a large collection of books, videos, teaching kits, professional
journals and other library resources on food and nutrition topics. Phone
NAL for more information. (301) 504-5755.
Website address: http://www.nal.usda.gov
• National Food Service Management Institute (NFSMI), University
of Mississippi
NFSMI at the University of Mississippi is a national resource for the child
nutrition programs. It provides information services and referral in all
areas of nutrition and school food service. NFSMI staff can give practical
answers to question regarding serving children with special nutritional
needs. Call the Help Desk at 1-800-321-3054, or (662) 915-7658.
Website address: http://www.nfsmi.org.
•
National Information Center for Children and Youth with
Disabilities (NICHCY)
NICHCY is an information and referral center for children with
disabilities and disability related issues which receives funding through
the U.S. Department of Education. Information specialists provide
information in English and Spanish regarding services about specific
disabilities, special education and related services, education programs,
family issues or disability organizations. The toll free number is 1-800695-0285.
NICHCY staff has prepared State Resource Sheets for each State which
can be downloaded from its web site. The resource sheet for your State
will help you locate government agencies, chapters of disability
organizations, parent training and information projects. The resource
sheet can also refer you to local sources of information and assistance.
Website address: http://www.nichcy.org
17
IV.
LEGAL CONCERNS AND LIABILITY IN WORKING
WITH CHILDREN WITH DISABILITES
A growing body of Federal law clearly intends that children with
disabilities have the same rights and privileges, and the same access to
benefits, such as school meals, as children without disabilities.
Consequently, schools which do not make appropriate program
accommodations for children with disabilities, could be found in violation
of Federal civil rights laws.
School administrators and food service staff should be aware of two issues
involving liability: (1) the school's responsibility for providing program
accommodations for children with disabilities and (2) the question of
personal responsibility in cases of negligence. These two issues are
discussed below.
A.
SCHOOL RESPONSIBILITY TO MAKE
ACCOMMODATIONS
Section 504
Rehabilitation Act of 1973
Section 504 of the Rehabilitation Act of 1973 specifically
mandates that:
"no otherwise qualified individual with a disability
shall solely by reason of his or her disability be
excluded from the participation in, be denied the
benefits of, or be subjected to discrimination under
any program or activity receiving Federal
financial assistance."
This mandate is incorporated in 7 CFR Part 15b, USDA’s
nondiscrimination regulations.
Individuals with Disabilities Education Act
Part B of the Individuals with Disabilities Education Act (IDEA) assists
States and school districts in making a "free appropriate public
education" available to eligible students.
18
Under IDEA, a "free appropriate public education" means special
education and related services provided under public supervision and
direction in conformity with an individualized education
program (IEP) at no cost to parents.
In appropriate situations, nutrition services could be considered “special
education" (specially designed instruction) or a “related service", (support
services required to assist a child with a disability to benefit from special
education).
Title II
Americans With Disabilities Act
Title II of the Americans with Disabilities Act (ADA), enacted in 1990,
requires equal availability and accessibility in State and local government
programs and services, including public schools.
In this respect, the ADA underscores the statutory prohibition of Section
504 of the Rehabilitation Act of 1973, against discrimination on the basis
of disability by programs receiving Federal funding, such as
reimbursement under the school meal programs.
Title II of the ADA does not impose any major new requirements on
school districts because the requirements of Title II and Section 504 are
similar. Virtually all school districts receive Federal financial assistance
and have been required to comply with Section 504 for many years.
Title III
Americans With Disabilities Act
Title III of the ADA extends requirements for public accommodations to
privately owned facilities.
All private schools participating in the federally funded child nutrition
programs must make accommodations to enable children with disabilities
to receive school meals.
Although religious organizations are exempt from the public
accommodations requirements of Title III, church-operated schools which
receive Federal funding assistance under the child nutrition programs
continue to be subject to the non-discrimination requirements of Section
504.
19
B.
PERSONAL RESPONSIBILITY IN CASES OF
NEGLIGENCE
In order to accommodate a child with a disability, the school must ensure
that both facilities and personnel are adequate to provide necessary
services.
In some cases, it may be advisable for specially trained personnel, such as
a registered dietitian to provide guidance to the school food service staff
on how to modify a child’s meals to comply with requirements as
provided in the licensed physician’s statement.
Moreover, for certain children with disabilities, it may be necessary to
have a nurse or trained health aide feed the child or have a specially
trained professional, such as a special education teacher, occupational
therapist, or speech therapist, assist the child to develop and improve his
or her eating skills.
Administering Feedings
For children requiring assistance in eating, the determination of who will
feed the child is a local school decision.
While the school food service is specifically responsible for providing the
necessary foods needed by a child with a disability, it is not the specific
responsibility of the school food service staff to physically feed the child.
Furthermore, schools should be aware that they could be held liable if
persons without sufficient training are performing tasks or activities such
as developing or modifying a diet order prescribed by a licensed physician
or administering tube feedings.
Diet Orders
If school food service staff have questions about the diet order, the
prescribed meal substitutions, or any other modifications that are required,
the child's physician and/or a registered dietitian should be consulted. If
the school food service director cannot obtain local level assistance, the
State agency should be consulted for technical assistance.
20
Under no circumstances should school food service staff diagnose health
conditions, perform a nutritional assessment, prescribe nutritional
requirements, or interpret, revise or change a diet order.
Negligence
If a mishap should occur, personal liability would normally depend on
whether or not the person responsible for the feeding has been negligent.
In these cases, a determination that a person acted negligently would be
made on the basis of State laws and the facts in the individual situation.
In general, negligence occurs when a person fails to exercise the care
expected of a prudent person.
Persons involved with special feeding operations should, therefore, make
sure that they thoroughly understand the required procedures and
techniques and are careful to follow instructions.
For specific guidance concerning personal liability, the school officials
should contact State or local legal counsel.
21
V.
SITUATIONS AND RESPONSES
In order to provide some practical guidelines, this section discusses
several situations which are relatively common and which have raised
questions in the past. These examples have been included because they
illustrate certain principles and give general direction on what schools and
institutions must do under the law. In all situations where a student’s IEP
indicates nutritional requirements or components, schools must make
these accommodations.
Remember that circumstances vary from case to case. Schools should not
automatically assume that the responses given in this section would
always apply. When an actual situation occurs which has elements
different from those discussed here, the State agency should be consulted
for guidance.
The examples in this section have been grouped under the following
topics:
• Meals and/or foods outside of the normal
•
•
•
•
•
•
•
meal service
Special needs which may or may not involve
disabilities
Responsibilities of food service management
companies and other food service operations
Feeding in separate facilities—generally not acceptable
Temporary disabilities
Complicated feedings
School food service account and
Documentation
22
A. MEALS AND/OR FOODS OUTSIDE OF THE NORMAL MEAL
SERVICE
Situation 1:
As part of the therapy for a child with a disability, the licensed physician
has required the child to consume six cans of cranberry juice a day. The
juice is to be served at regular intervals, and some of these servings would
occur outside of the normal school meal periods. Is the school food
service required to provide all of the servings of juice?
Response:
No. The general guideline in making accommodations is that children
with disabilities must be able to participate in and receive benefits from
programs that are available to children without disabilities.
In this example, the school food service would be required to provide (and
pay for) cranberry juice as part of the regular reimbursable breakfast,
lunch and/or snack service. However, the school food service would not
be required to pay for other servings throughout the school day unless
specified in the Individualized Education Plan (IEP).
It must be recognized that there will be exceptions to this general rule.
For example, residential child care institutions (RCCI), such
as juvenile correction facilities, may be required to provide additional
foods or servings since the child would have no other recourse for meals.
It must be stressed that such accommodation would depend on the specific
circumstances of each case and, in any event, would go beyond
obligations under the school nutrition programs.
In general, additional servings beyond what is required under the program
meal may, but need not, be charged to the nonprofit food service account.
23
Situation 2:
A child with a disability must have a full breakfast each morning. Is the
school food service required to provide a breakfast for this child even
though a breakfast program is not available for the general school
population?
Response:
As noted above, the school food service is not required to provide services
and meals to children with disabilities that are not otherwise available to
children who are not disabled. If the school does not have a breakfast
program already, it does not need to initiate a program exclusively for
children with disabilities.
However, if the IEP requires that a child receive a breakfast at school, the
school must provide the service, and may choose to have the school food
service handle the responsibility.
Another exception to the general rule concerns a child with a disability
who resides in a RCCI and requires special food service. In the case of
RCCIs, the institution serves as the child's home, and the child would have
no other recourse for meals. The RCCI must provide the child a full
breakfast, if this is specified in the licensed physician's statement or in the
IEP.
Situation 3:
A licensed physician has prescribed portion sizes that exceed the
minimum quantity requirements set forth in the regulations. Is the school
required to provide these additional quantities?
Response:
Yes. The school must provide the child food portions which exceed the
minimum quantity requirements, if specifically prescribed in the licensed
physician's statement.
24
B. SPECIAL NEEDS WHICH MAY OR MAY NOT INVOLVE
DISABILITIES
Situation 4:
A child has a life threatening allergy which causes an anaphylactic
reaction to peanuts. The slightest contact with peanuts or peanut
derivatives, usually peanut oil, could be fatal. To what lengths must the
food service go to accommodate the child? Is it sufficient for the school
food service to merely avoid obvious foods, such as peanut butter, or must
school food service staff research every ingredient and additive in
processed foods or regularly post all of the ingredients used in recipes?
Response:
The school has the responsibility to provide a safe, non-allergic meal to
the child if it is determined that the condition is disabling. To do so,
school food service staff must make sure that all food items offered to the
allergic child meet prescribed guidelines and are free of foods which are
suspected of causing the allergic reaction.
This means that the food labels or specifications will need to be checked
to ensure that they do not contain traces of such substances. In some
cases, the labels will provide enough information to make a reasonable
judgment possible. If they do not provide enough information, it is the
responsibility of the school food service to obtain the necessary
information to ensure that no allergic substances are present in the foods
served.
In some cases, it may be necessary to contact the supplier or the
manufacturer or to check with the State agency. Private organizations,
such as the Food Allergy and Anaphylaxis Network (see Appendix D),
may also be consulted for information and advice. It is also wise to check
with parents about certain foods and even provide them with advance
copies of menus.
The general rule in these situations is to exercise caution at all times. Do
not serve foods to children at risk for anaphylactic reactions, if you do not
know what is in those foods. It is important to recognize that a child may
be provided a meal, which is equivalent to the meal served to other
children, but not necessarily the same meal.
25
Sometimes, it will be advisable to prepare a separate meal "from scratch"
using ingredients that are allowed on the special diet rather than serving a
meal using processed foods.
Situation 5:
A child has a health condition that does not meet the definition of
"disability" set forth in the legislation and regulations. For example, the
child is overweight (but not “morbidly" so), or the child has elevated
blood cholesterol. Is the school obligated to accommodate the special
dietary needs of this child?
Response:
The school may make substitutions for children who are not considered to
be disabled, but who should avoid certain foods. However, the school is
not required to do so. When the school does elect to accommodate
children without disabilities, it must have a supporting statement, signed
by a recognized medical authority on file.
In most cases, the dietary needs of such children can be accommodated at
the food service site in schools and institutions where a variety of
nutritious foods are available for individual choice. In addition, the "offer
versus serve" provision which allows students the option to decline one or
two foods in the normal (reimbursable) school meal may be of assistance
in accommodating an individual's particular diet.
Situation 6:
A child's parents have requested that the school prepare a strict vegetarian
diet for their child based on a statement from a health food store "nutrition
advisor" who is not a licensed physician. Must the school comply with
this request?
Response:
No. The school is responsible only for accommodating those conditions
meeting the definition of disability as described in 7 CFR Part 15b.
Schools are not required to make food substitutions based on food choices
of a family or child regarding a healthful diet.
26
C. RESPONSIBILITIES OF FOOD SERVICE MANAGEMENT
COMPANIES (FSMC) AND OTHER FOOD SERVICE
OPERATIONS
Situation 7:
A school district has contracted with a FSMC to operate the school's food
service. Is the FSMC obligated to accommodate children with
disabilities?
Response:
Yes. The school is always required to ensure that any benefits available
for the general school population are equally available to children with
disabilities. Consequently, accommodations for these children must be
made regardless of whether the school district operates the food service
itself or contracts with an FSMC to do so.
However, as a procurement issue, accommodations for children with
disabilities must be included in the contract. School food authorities that
do not have any need for special dietary accommodations at the time a
FSMC bid is prepared should still include sufficient information in the bid
to ensure that the FSMC is aware that dietary accommodations may be
required during the term of the contract.
Situation 8:
Some schools purchase items from nationally recognized fast-food chains
and sell these items on an "a la carte" basis. These items are frequently
sold in a setting such as a kiosk which uses the chain's logo or otherwise
advertises the product. What obligation, if any, does the fast-food chain
have to provide alternative meals?
Response:
When the school purchases and sells the product itself, the fast-food chain
incurs no more obligations than any other wholesaler or retailer of food
products. Consequently, it is important that parents, school food service
staff, and other involved school personnel identify and discuss the
particular needs of children with special needs and take steps to ensure
such children, especially very young children, do not purchase "a la carte"
items which can be harmful to them.
27
Technically, food items sold strictly on an "a la carte" basis are not part of
a reimbursable meal. The food items are not subject to program
regulations as long as they do not belong to any of the categories of foods
of minimal nutritional value. The fast-food chain may not be under the
obligation to provide alternate food items, unless this is explicitly stated in
its contract to vend food items to the school.
However, schools would be well advised to obtain from the food chain or
vendor(s) specific information on the ingredients in the food products
purchased, particularly, if there are children diagnosed at risk of severe
food allergies who are participating in the food service. Furthermore, the
school may want to consider including such product information as a
specification in its contract with the chain or vendor
D. FEEDING IN SEPARATE FACILITIES – GENERALLY
NOT ACCEPTABLE
Situation 9:
A school wishes to serve meals to children with disabilities in an area
separate from the cafeteria where the majority of school children eat. May
the school establish a separate facility for these children?
Response:
Federal civil rights legislation, including Section 504 of the Rehabilitation
Act of 1973, IDEA, and Title II of the ADA, requires that in providing for
or arranging for the provision of nonacademic services and extracurricular
activities, including meals, school districts must ensure that students with
disabilities participate along with children without disabilities to the
maximum extent appropriate to the needs of students with disabilities.
In general, children with disabilities must be allowed to participate with
other children to the maximum extent appropriate. In this way, the child
has the opportunity to interact with and learn from children without
disabilities. The school must not segregate children with disabilities on
the basis of convenience to the school or to other children.
28
In rare instances, however, it may be to a child's benefit to be served
separately. For instance, a child with severe motor disabilities may be
able to receive individualized attention in handling eating utensils if a
special education specialist is able to work with them outside the cafeteria.
Nevertheless, it must be emphasized that in all cases, the decision to feed
children with disabilities separately must always be based on what is
appropriate to meet the needs of the children. Schools cannot segregate
children with disabilities based on the convenience of the school or other
children.
E. TEMPORARY DISABILITIES
Situation 10:
A child was involved in an accident and underwent major oral surgery.
As a result, the child will be unable to consume food for a period of time
unless the texture is modified. Is the school obligated to make this
accommodation even though the child will not be permanently disabled?
Response:
A child’s whose disability restricts their diet must be provided
substitutions or modifications to foods regardless of the duration of the
disability.
F. COMPLICATED FEEDINGS
Situation 11:
A child enrolled in the school will require tube feedings. Is the food
service only required to pay for and provide the food, or are the costs for
the school nurse, an aide or a specially trained professional to administer
the feeding also assigned to the food service?
Response:
It must be emphasized that the overall responsibility for accommodating
children with disabilities rests with the school district. The school district
administration is responsible for allocating the district’s costs of
accommodating children with disabilities and for deciding which
personnel will work with individual children.
29
In most instances involving food substitutions, the school food service
account will be used to pay the cost of special food and food preparation
equipment and food service personnel will generally be responsible for
providing the alternate meal. For example, if a child must have a pureed
meal, it is reasonable to expect the school food service to purchase a
blender or food processor, and to have the meal prepared by the food
service staff.
In the case of more delicate operations, such as tube feeding, it is
advisable that commercial nutritive formulas, prescribed by a licensed
physician, and specially designed for tube feedings, be used rather than a
school blenderized formula, which may be subject to spoilage and may not
always have the correct consistency or nutritive content. Proper
administration of this type of feeding generally requires the skills of
specially trained personnel, such as nurses or the special trained aides who
regularly work with the child.
Special labor costs may be covered through special education funds, if the
child has an IEP. If the child does not have an IEP, these costs may, as
appropriate, be charged in part to the food service account, or may be
assigned to the school district’s general fund or to other funding sources.
Situation 12:
A child with a disability is on a number of medications. The physician’s
statement is well defined and includes menus with specific foods. If a
situation arises where specific foods are out of stock, should school food
service make substitutions on an "as necessary" basis?
Response:
No. School food service staff cannot decide what substitutions are
appropriate for a given child. Food service staff should not choose the
substitutions themselves because a child may be on a specific medication,
which could interact in a negative way with a particular food item.
Ideally, a list of appropriate substitutions should accompany the menus
and the foods should be on hand on a regular basis. If such a list is not
available, school food service staff must ask parents to obtain from the
child’s physician (or the individual who planned the child's menus) a list
of those foods that may be substituted.
30
G. SCHOOL FOOD SERVICE ACCOUNT
Situation 13:
A child with a disability needs to consume six cans of a nutritional
supplement during the school day: two cans at breakfast, one can as a midmorning snack, two cans at lunch, and one can as a mid-afternoon snack.
The cost of the breakfast and lunch supplements is allowable food service
expenses. If the school chooses to offer the additional supplement at the
mid-morning and mid-afternoon snack period, are these allowable costs to
the food service account?
Response:
Yes. While it is not required that these costs be charged to the nonprofit
school food service account, these supplements are a legitimate charge to
the food service account.
Situation 14:
A child with a disability requires the services of the school nurse for
assistance in feeding at lunch. Can the food service account be billed for
the services of non-food service personnel such as the school nurse or
special aide who may be assisting in the feeding of the child or other
nutrition related activity?
Response:
Yes. The services of any personnel necessary to the food service can be
paid by the food service account on a pro rata basis. It must be
emphasized, however, that the food service account may only pay for the
amount of time that the person actually spends on activities related to the
school food service. If a school nurse spends one hour per day feeding a
child with a special need, then only that portion of his/her salary can be
charged to the food service account, not the entire salary. If the child is
receiving special education and the child's IEP includes a nutrition or
feeding component, special education funds may be available to the school
to provide required services for the child.
31
H. DOCUMENTATION
Situation 15:
The physician's statement only specifies the medical disability, not the
required food substitutions. What should the food service director do?
Response:
An appropriate school official (such as the food service director, food
service manager or school nurse) must ask parents to obtain more written
information from the physician concerning the substitutions or
modifications the child requires. If difficulties arise in obtaining the
needed information, the parent(s) should be advised of the problem and
asked to work with the school to obtain a complete medical statement for
the child. It is important that the family understand that the school is
unable to provide food substitutions or modifications without an adequate
diet order or diet prescription.
In some cases, it may be appropriate and helpful for the physician to
provide a written referral to a registered dietitian or other qualified
professional for diet substitutions. For further guidance or referral to a
registered dietitian, school food service directors may contact their State
agency.
32
VI.
SAMPLE DOCUMENTATION
FOR SPECIAL DIETARY NEEDS
It is important to document the special nutritional needs of children
requiring dietary modifications. Keeping a record will protect the school
and minimize misunderstandings. The medical statement does not have to
be renewed each year if there are no changes in the diet order. Be sure to
note and date any changes in the child’s medical condition or diet order.
A.
EATING/FEEDING EVALUATION
Figure 1 includes a sample Eating and Feeding Evaluation: Children with
Special Needs. This form should be completed by a parent, a physician,
or other recognized medical authority.
B.
INFORMATION CARD
Figure 2 gives an example of an information card, which can be used
daily by school food service staff in the kitchen to prepare meals for the
children who have special dietary or medical needs.
(The Information Card and the Eating/Feeding
Evaluation Form were adapted, with permission,
from forms developed by Susan Woods, R.D., for
Bibb County Schools in Georgia.)
33
FIGURE 1.
EATING AND FEEDING EVALUATION:
CHILDREN WITH SPECIAL NEEDS
PART A
Age
Student’s Name
Grade Level
Name of School
Does the child have a disability? If Yes, describe the major life activities affected by the
disability.
Classroom
Yes
No
No
Does the child have special nutritional or feeding needs? If Yes, complete Part B of this Yes
form and have it signed by a licensed physician.
If the child is not disabled, does the child have special nutritional or feeding needs? If
Yes
No
Yes, complete Part B of this form and have it signed by a recognized medical authority.
If the child does not require special meals, the parent can sign at the bottom and return the form to the school food
service.
PART B
List any dietary restrictions or special diet.
List any allergies or food intolerances to avoid.
List foods to be substituted.
List foods that need the following change in texture. If all foods need to be prepared in this manner, indicate “All.”
Cut up or chopped into bite size pieces:
Finely ground:
Pureed:
List any special equipment or utensils that are needed.
Indicate any other comments about the child’s eating or feeding patterns.
Parent’s Signature
Date:
Physician or Medical Authority’s Signature
Date:
34
FIGURE 2.
INFORMATION CARD
Student’s Name
Teacher’s Name
Special Diet or Dietary Restrictions
Food Allergies or Intolerances
Food Substitutions
Foods Requiring Texture Modifications:
Chopped:
Finely Ground:
Pureed or Blended:
Other Diet Modifications:
Feeding Techniques
Supplemental Feedings
Physician or Medical Authority:
Name
Telephone
Fax
Additional Contact:
Name
Additional Contact:
Name
Telephone
Fax
Telephone
Fax
School Food Service Representative/Person Completing Form:
Title
Signature
Date:
35
VII.
GLOSSARY
AMERICANS WITH DISABILITIES ACT (ADA)
Comprehensive legislation, signed into law on July 26, 1990, that
creates new rights and extends existing rights for Americans with
disabilities. Title II of the Act is especially significant for the
school nutrition programs, as it requires equal availability and
accessibility in State and local government programs and services,
including public schools.
ANAPHYLAXIS/ANAPHYLACTIC REACTION
A rare but potentially fatal condition in which several different
parts of the body experience food-allergic reactions at the same
time. Symptoms may progress rapidly and include severe itching,
hives, sweating, swelling of the throat, breathing difficulties,
lowered blood pressure, unconsciousness and even death.
DISABILITY
Under Section 504 of the Rehabilitation Act of 1973 and the
Americans with Disabilities Act, "person with a disability" means
any person who has a physical or mental impairment which
substantially limits one or more major life activities, has a record
of such an impairment, or is regarded as having such an
impairment. The term "physical or mental impairment" includes,
but is not limited to, such diseases and conditions as orthopedic,
visual, speech, and hearing impairments; cerebral palsy; epilepsy;
muscular dystrophy; multiple sclerosis; cancer; heart disease;
metabolic diseases such as diabetes and phenylketonuria (PKU);
food anaphylaxis; mental retardation; emotional illness; and drug
addiction and alcoholism. Major life activities covered by this
definition include caring for one's self, eating, performing manual
tasks, walking, seeing, hearing, speaking, breathing, learning and
working.
36
Under the Individuals with Disabilities Education Act (IDEA), the
term "disability" refers to specified physical, mental, emotional, or
sense impairments, which adversely affect a child's educational
performance. Thirteen recognized disability categories, which
establish a child’s need for special education and related services,
are listed in IDEA. These disabilities include autism; deafblindness; deafness or other hearing impairments; mental
retardation; orthopedic impairments; other health impairments due
to acute health problems (such as a heart condition, epilepsy, or
tuberculosis); emotional disturbance; specific learning disabilities;
speech or language impairment; traumatic brain injury; visual
impairment, including blindness, which adversely affects a child's
educational performance.
FOOD ALLERGY
Hypersensitivity from an abnormal response of the body's immune
system to food or food additives that would otherwise be
considered harmless. Many of the true food allergy symptoms
often resemble allergic reactions to other substances, such as
penicillin, drugs, bee stings, hives and itching.
FOOD INTOLERANCE
An adverse food-induced reaction that does not involve the body's
immune system. Lactose intolerance is one example of a food
intolerance. A person with lactose intolerance lacks an enzyme
that is needed to digest milk sugar. When milk products are
consumed symptoms such as gas, bloating, and abdominal pain
may occur.
FREE APPROPRIATE PUBLIC EDUCATION (FAPE)
Under the Individuals with Disabilities Education Act , FAPE
means special education and related services provided under public
supervision and direction, in conformity with an individualized
education program (IEP), and at no cost to parents. In appropriate
situations, nutrition services could be deemed "special education"
(specially designed instruction) or a "related service" (support
services required to assist a child with a disability to benefit from
special education).
37
INDIVIDUALS WITH DISABILITIES EDUCATION ACT
(IDEA)
Formerly the Education of the Handicapped Act, originally enacted
in 1975, IDEA includes Part B, the basic grants to States program,
which provides Federal funds to assist States and school districts in
making a free appropriate public education available to eligible
students with specified disabilities.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
The Individualized Education Program or IEP means a written
statement for a child with a disability that is developed, reviewed,
and revised in a meeting in accordance with the IDEA and its
implementing regulations. The IEP is the cornerstone of the
student’s educational program that contains the program of special
education and related services to be provided to a child with a
disability covered under the IDEA.
NOTE: Some states supplement the IEP with a written statement
specifically designed to address a student’s nutritional needs.
Other states employ a “Health Care Plan” to address the nutritional
needs of their students. For ease of reference the term “IEP” is
used to reflect the IEP as well as any written statement designating
the required nutrition services.
OSTEOPATHIC PHYSICIAN OR DOCTOR OF
OSTEOPATHIC MEDICINE
A fully trained physician who is licensed by the State to prescribe
medication or to perform surgery. The American Medical
Association includes osteopathic physicians as equal members
with M.D.s. The majority of doctors of osteopathic medicine are
primary care physicians.
38
SPECIAL DIETARY NEEDS
An individual who does not have a disability, as defined in 7 CFR
15(b), but is unable to consume a particular food because of a
medical or other special dietary condition is considered to have a
special dietary need. The individual's special dietary need and the
needed substitution(s) must be supported by a medical statement
from a licensed medical authority or other appropriate health
professional as designated by the State. A person with special
dietary needs may have a food allergy or intolerance (for example,
lactose intolerance) but does not have life-threatening
(anaphylactic) reactions when exposed to food(s) to which he/she
is allergic.
RECOGNIZED MEDICAL AUTHORITY
Physicians, physician assistants, nurse practitioners; or other
professionals specified by the State agency. See FNS Instruction
783-2, Revision 2, Meal Substitutions for Medical or Other Special
Dietary Reasons.
REGISTERED DIETITIAN (R.D.)
A nutrition professional who has earned a B.S. or B.A. degree, met
basic academic and clinical training requirements, and passed the
qualifying examination for professional registration for dietetics.
The registration program is maintained by the Commission on
Dietetic Registration of the American Dietetic Association. R.D.s
can answer questions on special diets, menu planning, and related
topics and conduct a nutritional assessment. An R.D. may work
with the physician and school staff to assist in meeting a child's
special nutritional needs and to ensure that menus are in
compliance with the physician's diet order.
REHABILITATION ACT OF 1973
The principal Federal legislation aimed at promoting the
employment and independent living of people with disabilities.
Section 504 of Title V of this legislation prohibits discrimination
against qualified persons with disabilities in the programs or
activities (including hiring practices) of any organization receiving
Federal financial assistance.
39
APPENDICES
40
Appendix A
UNITED STATES DEPARTMENT OF AGRICULTURE
Food and Nutrition Service
3101 Park Center Drive
Alexandria, VA 22302
ACTION BY:
FNS INSTRUCTION 783-2
REV. 2
Regional Directors
Special Nutrition Programs
SOURCE CITATION:
Rehabilitation Act of 1973, Section 504;
7 CFR Part 15b; 7 CFR Sections 210.10(i)(1), 210.23(b),
215.14, 220.8(f), 225.16(g)(4), and 226.20(h)
Meal Substitutions for Medical
or Other Special Dietary Reasons
Child Nutrition Program regulations require participating school food authorities,
institutions and sponsors to offer to all participants breakfasts, lunches, suppers,
supplements and milk which meet the meal patterns identified in the Program regulations.
Departmental regulations further require substitutions to the standard meal patterns for
participants who are considered handicapped under 7 CFR Part 15b and whose handicap
restricts their diet; and permit substitutions for other participants who are not
handicapped but are unable to consume regular Program meals because of medical or
other special dietary needs. The provisions requiring substitutions for handicapped
participants respond to the requirements of Section 504 of the Rehabilitation Act of 1973
and to the U.S. Department of Agriculture's implementing regulations, 7 CFR Part 15b,
which provide that no otherwise qualified handicapped individuals shall, solely on the
basis of handicap, be excluded from participation in, be denied benefit of, or subjected to
discrimination under any program or activity receiving Federal financial assistance.
This Instruction outlines the policy for food substitutions and other modifications in the
meal patterns necessary to meet the dietary requirements of Program participants with
handicaps and with other special dietary needs. School food authorities, institutions and
sponsors are required to offer Program meals to participants with handicaps whenever
Program meals are offered to the general populations served by the Programs. School
food authorities, institutions and sponsors should be aware that the
DISTRIBUTION: MANUAL MAINTENANCE
5,6,7,11,12
INSTRUCTIONS:
Remove FNS Instruction 783-2, Rev. 1,
from Manual. Insert this Instruction.
41
RESPONSIBLE FOR
PREPARATION AND
MAINTENANCE:
CND-100
PAGE 1
10-14-94
FNS INSTRUCTION 783-2
REV. 2
Individuals with Disabilities Education Act (IDEA) imposes requirements on States
which may affect them, including the service of meals even when such service is not
required by the Child Nutrition Programs.
For example, the individualized education program developed for a child under the IDEA
may require a meal to be served outside of the regular meal schedule for Program meals
or may require a breakfast to be served in a school food authority which does not
participate in the School Breakfast Program. While the school food authority, institution
or sponsor may not claim these meals as Program meals, it may use the same food service
facilities or food service management company to provide these meals as it uses to
provide Program meals, and Program funds may be used to pay for the costs associated
with the IDEA-required meals. Inquiries regarding the IDEA's requirements should be
directed to the U.S. Department of Education, the Agency responsible for the IDEA's
administration and enforcement.
School food authorities, institutions and sponsors may also have responsibilities under the
Americans with Disabilities Act (ADA). Inquiries regarding a school food authority's,
institution's or sponsor's responsibilities under the ADA should be directed to the U.S.
Department of Education, the agency responsible for the enforcement of the ADA's
requirements in elementary and secondary education systems.
I
HANDICAPPED PARTICIPANTS
"Handicapped person" is defined in 7 CFR 15b.3(i) as any person who has "a physical or
mental impairment which substantially limits one or more major life activities, has a
record of such impairment, or is regarded as having such an impairment.” (See Exhibit
A, 7 CFR 15b.3.) "Major -life activities" are defined in 7 CFR 15b.3(k) as "functions
such as caring for one's self, performing manual tasks, walking, seeing, hearing,
speaking, breathing, learning and working.” School food authorities, institutions and
sponsors participating in the Child Nutrition Programs are required to make substitutions
or modifications to the meal patterns for those participants with handicaps who are
unable to consume the meals offered to nonhandicapped participants.
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FNS INSTRUCTION 783-2
REV.2
Determinations of whether or not a participant has a handicap which restricts his or her
diet are to be made on an individual basis by a licensed physician. (Licensed physicians
include Doctors of Osteopathy in many states.) The physician's medical statement of the
participant's handicap must be based on the regulatory criteria for "handicapped person"
defined in 7 CFR Part 15b.3(i) and contain a finding that the handicap restricts the
participant's diet. In those cases in which the school food authority, institution or sponsor
has consulted with the physician issuing the statement and is still unclear whether the
medical statement meets the regulatory criteria, the school food authority, institution or
sponsor may consult the State agency.
A participant whose handicap restricts his or her diet shall be provided substitutions in
foods only when supported by a statement signed by a licensed physician. The medical
statement shall identify:
A.
The participant's handicap and an explanation of why the handicap restricts the
participant's diet;
B.
The major life activity affected by the handicap; and
C.
The food or foods to be omitted from the participant's diet, and the food or choice
of foods that must be substituted.
If the handicap would require caloric modifications or the substitution of a liquid
nutritive formula, for example, this information must be included in the statement. If the
handicapped participant requires only textural modification(s) to the regular Program meal,
as opposed to a meal pattern modification, the medical statement is recommended, but
not required. In such cases, the purpose of the statement is to assist the school food
authority, institution or sponsor in providing the appropriate textural modification(s).
Unless otherwise specified by the physician, the meals modified for texture will consist
only of food items and quantities specified in the regular menus.
The State agency should make 7 CFR 15b.3 (Exhibit A) available to school food
authorities, institutions and sponsors. The school food authority, institution or sponsor
should also provide parents or guardians with 7 CFR Part 15b.3, so that their physicians
may correctly assess whether an individual's handicap meets the regulatory criteria.
School food authorities, institutions and sponsors should use the services of a Registered
Dietitian to assist in implementing the medical statement, as appropriate.
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FNS INSTRUCTION 783-2
REV. 2
Generally, participants with food allergies or intolerances, or obese participants are not
"handicapped persons", as defined in 7 CFR 15b.3(i), and school food authorities,
institutions and sponsors are not required to make substitutions for them. However, when
in the physician's assessment food allergies may result in severe, life-threatening
reactions (anaphylactic reactions) or the obesity is severe enough to substantially limit a
major life activity, the participant then meets the definition of "handicapped person", and
the food service personnel must make the substitutions prescribed by the physician.
II
PARTICIPANTS WITH OTHER SPECIAL DIETARY NEEDS
School food authorities, institutions or sponsors may, at their discretion, make
substitutions for individual participants who are not "handicapped persons", as defined in
7 CFR Part 15b.3(i), but who are unable to consume a food item because of medical or
other special dietary needs. Such substitutions may only be made on a case-by-case basis
when supported by a statement signed by a recognized medical authority. In these cases,
recognized medical authorities may include physicians, physician assistants, nurse
practitioners or other professionals specified by the State agency.
For these nonhandicapped participants, the supporting statement shall include:
A. An identification of the medical or other special dietary need which restricts
the participant's diet; and
B. The food or foods to be omitted from the participant's diet, and the food or
choice of foods that may be substituted.
School food authorities, institutions and sponsors are not required to make substitutions
for participants whose conditions do not meet the definition of "handicapped person" set
forth in 7 CFR 15b.3(i). For example, individuals who are overweight or have elevated
blood cholesterol generally do not meet the definition of handicapped person, and thus
school food authorities, institutions, and sponsors are not required to make meal
substitutions for them. In fact, in most cases, the special dietary needs of nonhandicapped
participants may be managed within the normal Program meal service when a wellplanned
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FNS INSTRUCTION 783-2
REV. 2
variety of nutritious foods is available to children, and/or "offer versus serve” is available
and implemented.
III
REIMBURSEMENT AND AVAILABILITY OF SUBSTITUTIONS
Reimbursement for meals served with an authorized substitute food to handicapped
participants or to participants with other special dietary needs shall be claimed at the
same reimbursement rate as meals which meet the meal pattern. Furthermore, there shall
not be a supplementary charge for the substituted food item(s) to either a handicapped
participant or to a participant with other special dietary needs. 7 CFR 15b.26(d)(1)
specifies that, in providing food services, recipients of Federal financial assistance "may
not discriminate on the basis of handicap" and "shall serve special meals, at no extra
charge, to students whose handicap restricts their diet." While any additional costs for
substituted foods are considered allowable Program costs, no additional Child Nutrition
Program reimbursement is available. Sources of supplemental funding may include
special education funds (if the substituted food is specified in the child's individualized
education program); the general account of the school food authority, institution or
sponsor; or, for school food authorities, the nonprofit school food service account.
IV
ACCESSIBILITY
7 CFR 15b.26(d)(2) provides: "Where existing food service facilities are not completely
accessible and usable, recipients may provide aides or use other equally effective
methods to serve food to handicapped persons." The school food authority, institution or
sponsor is responsible for the accessibility of food service sites and for ensuring the
provision of aides, where needed. As with additional costs for substituted foods, any
additional costs for adaptive feeding equipment or for aides are considered allowable
costs. However, no additional Child Nutrition Program reimbursement is available.
Sources of supplemental funding may include special education funds (if specified in the
child's individualized education program); the general account of the school food
authority, institution or sponsor; or, for school food authorities, the nonprofit school food
service account.
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FNS INSTRUCTION 783-2
REV. 2
7 CFR 15b.26(d)(2) further provides that recipients provide all food services in the most
integrated setting appropriate to the needs of the handicapped persons as required by 7
CFR 15b.23(b).
That section requires Program recipients to ensure that handicapped persons participate
with nonhandicapped persons to the maximum extent appropriate to the needs of the
handicapped person in question.
V COOPERATION
When implementing the guidelines of this Instruction, food service personnel should
work closely with the parent(s) or responsible family member(s) and with all other
school, child care, medical and community personnel who are responsible for the health,
well-being and education of participants with handicaps or with other special dietary
needs to ensure that reasonable accommodations are made to allow such individuals’
participation in the meal service. This cooperation is particularly important when
accommodating children or elderly adults whose handicapping conditions require
significant modifications or personal assistance.
ALBERTA C. FROST
Director
Child Nutrition Division
Page 6
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46
Exhibit A
Office of the Secretary, USDA
§ 15b.3
§ 15b.3
Definitions.
As used in this part, the term or
phrase:
(a) The Act means the Rehabilitation
Act of 1973, Public Law 93–112, 87 Stat.
390 (1973), as amended by the Rehabilitation Act Amendments of 1974, Public
Law 93–651, 89 Stat. 2 (1974) and Public
Law 93–516, 88 Stat. 1617 (1974) and the
Rehabilitation, Comprehensive Services and Developmental Disabilities
Amendments of 1978, Public Law 95–602,
92 Stat. 2955 (1978). The Act appears at
29 U.S.C. 701–794.
(b) Section 504 means section 504 of
the Act, 29 U.S.C. 794.
(c) Education of the Handicapped Act
means the Education of the Handicapped Act, Public Law 92–230, Title
VI, 84 Stat. 175 (1970), as amended by
the Education of the Handicapped
Amendments of 1974, Public Law 93–380,
Title VI, 88 Stat. 576 (1974), the Education for All Handicapped Children
Act of 1975, Public Law 94–142, 89 Stat.
773 (1975), and the Education of the
Handicapped Amendments of 1977, Public Law 95–49, 91 Stat. 230 (1977). The
Education of the Handicapped Act appears at 20 U.S.C. 1401–1461.
(d) Department means the Department
of Agriculture and includes each of its
operating agencies and other organizational units.
(e) Secretary means the Secretary of
Agriculture or any officer or employee
of the Department to whom the Secretary has delegated or may delegate
the authority to act under the regulations of this part.
(f) Recipient means any State or its
political subdivision, any instrumentality of a State or its political subdivision, any public or private agency,
institution, organization, or other entity, or any person to which Federal financial assistance is extended directly
or through another recipient, including
any successor, assignee, or transferee
of a recipient, but excluding the ultimate beneficiary of the assistance.
(g) Federal financial assistance or assistance means any grant, contract
(other than a procurement contract or
a contract of insurance or guaranty),
cooperative agreement, formula allocation, loan, or any other arrangement
by which the Department provides or
otherwise makes available assistance
in the form of:
(1) Funds;
(2) Services of Federal personnel;
(3) Real and personal Federal property or any interest in Federal property, including:
(i) A sale, transfer, lease or use (on
other than a casual or transient basis)
of Federal property for less than fair
market value, for reduced consideration or in recognition of the public
nature of the recipient’s program or activity; and
(ii) Proceeds from a subsequent sale,
transfer or lease of Federal property if
the Federal share of its fair market
value is not returned to the Federal
Government.
(4) Any other thing of value.
(h) Facility means all or any portion
of buildings, structures, equipment,
roads, walks, parking lots, or other
real or personal property or interest in
such property.
(i) Handicapped person means any person who has a physical or mental impairment which substantially limits
one or more major life activities, has a
record of such an impairment, or is regarded as having such an impairment.
(j) Physical or mental impairment
means (1) any physiological disorder or
condition, cosmetic disfigurement, or
anatomical loss affecting one or more
of the following body systems: Neurological; musculoskeletal; special sense
organs; respiratory, including speech
organs; cardiovascular; reproductive;
digestive; genitourinary; hemic and
lymphatic; skin; and endocrine; or (2)
any mental or psychological disorder,
such as mental retardation, organic
brain syndrome, emotional or mental
illness, and specific learning disabilities. The term physical or mental impairment includes, but is not limited to,
such diseases and conditions as orthopedic, visual, speech, and hearing impairments; cerebral palsy; epilepsy;
47
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§ 15b.4
7 CFR Subtitle A (1–1–01 Edition)
muscular dystrophy; multiple sclerosis,
cancer; heart disease; diabetes; mental
retardation; emotional illness; and
drug addiction and alcoholism.
(k) Major life activities means functions such as caring for one’s self, performing manual tasks, walking, seeing,
hearing, speaking, breathing, learning
and working.
(l) Has a record of such an impairment
means has a history of, or has been
misclassified as having, a mental or
physical impairment that substantially
limits one or more major life activities.
(m) Is regarded as having an impairment means (1) has a physical or mental impairment that does not substantially limit major life activities but
that is treated by a recipient as constituting such a limitation; (2) has a
physical or mental impairment that
substantially limits major life activities only as a result of the attitudes of
others towards such impairments, or
(3) has none of the impairments defined
in paragraph (j) of this section but is
treated by a recipient as having such
an impairment.
(n) Qualified handicapped person (used
synonymously with otherwise qualified
handicapped individual) means:
(1) With respect to employment, a
handicapped person who, with reasonable accommodation, can perform the
essential functions of the job in question, but the term does not include any
individual who is an alcoholic or drug
abuser whose current use of alcohol or
drugs prevents such individual from
performing the duties of the job in
question or whose employment, by reason of such current alcohol or drug
abuse, would constitute a direct threat
to property or the safety of others;
(2) With respect to public preschool,
elementary, secondary, or adult educational services, a handicapped person, (i) of an age during which nonhandicapped persons are provided such
services, (ii) of an age during which it
is mandatory under State law to provide such services to handicapped persons, or (iii) to whom a State is required to provide a free appropriate
public education under section 612 of
the Education of the Handicapped Act;
and
(3) With respect to postsecondary and
vocational education services, a handicapped person who meets all academic
and technical standards requisite to
admission or participation in the recipient’s education program or activity;
(4) With respect to other services, a
handicapped person who meets the essential eligibility requirements for the
receipt of such services.
(o) Handicap means any condition or
characteristic that renders a person a
handicapped person as defined in paragraph (i) of this section.
(p) For purposes of § 15b.18(d), Historic
preservation programs means programs
receiving Federal financial assistance
that has preservation of historic properties as a primary purpose.
(q) For purposes of § 15b.18(e), Historic
properties means those buildings or facilities that are eligible for listing in
the National Register of Historic
Places, or such properties designated
as historic under a statute of the appropriate State or local government
body.
(r) For purposes of § 15b.18(d), Substantial impairment means a significant
loss of the integrity of finished materials, design quality or special character which loss results from a permanent alteration.
[47 FR 25470, June 11, 1982, as amended at 55
FR 52139, Dec. 19, 1990]
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APPENDIX B
USDA, Food and Nutrition Service
Regional Directors
Regional Director
Mid-Atlantic Regional Office (MARO),
USDA, FNS, SNP
Mercer Corporate Park
300 Corporate Boulevard
Robbinsville, NJ 08691-1598
609-259-5025
Regional Director
Midwest Regional Office (MWRO),
USDA, FNS, SNP
77 West Jackson Blvd
20th Floor
Chicago, IL 60604-3507
312-353-6664
Regional Director
Mountain Plains Regional Office (MPRO),
USDA, FNS, SNP
1244 Speer Boulevard
Suite 903
Denver, CO 80204
303-844-0300
Regional Director
Northeast Regional Office (NERO),
USDA, FNS, SNP
10 Causeway Street
Room 501
Boston, MA 02222-1065
617-565-6370
Regional Director
Southeast Regional Office (SERO),
USDA, FNS, SNP
61 Forsyth Street, SW
Room 8T36
Atlanta, GA 30303
404-562-1800
Regional Director
Southwest Regional Office (SWRO),
USDA, FNS, SNP
1100 Commerce Street
Room 5C30
Dallas, TX 75242
214-290-9800
Regional Director
Western Regional Office (WRO),
USDA, FNS, SNP
550 Kearny Street
Room 400
San Francisco, CA 94108
415-705-2229
Mid-Atlantic Regional States
Delaware, Virginia, District of Columbia, Virgin
Islands, Maryland, West Virginia, New Jersey,
Pennsylvania, Puerto Rico
Midwest Regional States
Illinois, Indiana, Michigan, Minnesota, Ohio
Wisconsin
Mountain Plains Regional States
Colorado, South Dakota, Iowa, North Dakota,
Kansas, Utah, Missouri, Wyoming, Montana
Nebraska
Northeast Regional States
Connecticut, Vermont, Maine, Massachusetts,
New Hampshire, New York, Rhode Island
Southeast Regional States
Alabama, South Carolina, Florida, Georgia,
Kentucky, Tennessee, Mississippi, North Carolina
Southwest Regional States
Arkansas, Louisiana, New Mexico, Oklahoma,
Texas
Western Regional States
Alaska, Oregon, American Samoa, Arizona,
Washington, California, Guam, Hawaii, Trust
Territories, Idaho, Nevada, Commonwealth of the
Northern Mariana Islands
49
APPENDIX B(continued)
Regional Civil Rights Offices
Regional Director MARO
Civil Rights
Mercer Corporate Park
300 Corporate Boulevard
Robbinsville, NJ 08691-1598
609-259-5123
Regional Director MWRO
Civil Rights
77 West Jackson Blvd
20th Floor
Chicago, IL 60604-3507
312-353-3353
Regional Director MPRO
Civil Rights
1244 Speer Boulevard
Suite 903
Denver, CO 80204
303-844-0307
Regional Director NERO
Civil Rights
10 Causeway Street
Room 501
Boston, MA 02222-1065
617-565-6424
Regional Director SERO
Civil Rights
61 Forsyth Street, SW
Room 8t36
Atlanta, GA 30303
404-562-1808
Regional Director SWRO
Civil Rights
1100 Commerce Street
Room 5-A-6
Dallas, TX 75242
214-290-9820
Regional Director WRO
Civil Rights
550 Kearny Street
Room 400
San Francisco, CA 94108
415-705-1322
Mid-Atlantic Regional States
Delaware, Virginia, District of Columbia,
Virgin Islands, Maryland, West Virginia, New
Jersey, Puerto Rico, Pennsylvania
Midwest Regional States:
Illinois, Wisconsin, Indiana, Michigan,
Minnesota, Ohio
Mountain Plains Regional States:
Colorado, South Dakota, Iowa, North Dakota,
Kansas, Utah, Missouri, Wyoming, Montana,
Nebraska
Northeast Regional States
Connecticut, Vermont, Maine, Rhode Island,
Massachusetts, New Hampshire, New York
Southeast Regional States:
Alabama, South Carolina, Florida, Georgia,
Kentucky, Tennessee, Mississippi, North
Carolina
Southwest Regional States:
Arkansas, Louisiana, New Mexico, Oklahoma,
Texas
Western Regional States:
Alaska, Oregon, American Samoa, Arizona,
Washington, California, Guam, Hawaii, Trust
Territories, Idaho, Nevada, Commonwealth of
the Northern Mariana Islands
50
APPENDIX C
U.S. Department of Health and Human Services
Regional Contacts
Region I
Connecticut, Maine Massachusetts, New Hampshire, Rhode Island, Vermont
Boston Regional Office
John F. Kennedy Federal Building
Boston, MA 02203-0003
Medicaid Associate Regional Administrator
617-565-1223
EPSDT and MCH Regional Coordinator
617-565-1243
Region II
New Jersey, New York Puerto Rico, Virgin Islands
New York Regional Office
26 Federal Plaza, Room 3800
New York, NY 10278-0063
Medicaid Associate Regional Administrator
EPSDT and MCH Regional Coordinator
212-264-2058
212-264-3978
Region III
Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia
Philadelphia Regional Office
The Public Ledger Building
150 South Independence Mall West
Philadelphia, PA 19106
Medicaid Associate Regional Administrator (EPSDT)
215-861-4220
MCH Regional Coordinator
215-861-4252
Region IV
Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South
Carolina, Tennessee
Atlanta Regional Office
Atlanta Federal Center,Suite 4T20
61 Forsyth Street, SW
Atlanta, GA 30303-8909
Medicaid Associate Regional Administrator
404-562-7401
EPSDT and MCH Regional Coordinator
404-562-7465
51
APPENDIX C
U.S. Department of Health and Human Services
Regional Contacts
Region V
Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin
Chicago Regional Office
233 N. Michigan Ave., Suite 600
Chicago, IL 60601-5519
Medicaid Associate Regional Administrator
EPSDT and MCH Regional Coordinator
312-353-2702
312-353-3721
Region VI
Arkansas, Louisiana, New Mexico, Oklahoma, Texas
Dallas Regional Office
1301 Young St. Room 833, 8th. Fl.
Dallas, TX 75202
Medicaid Associate Regional Administrator
EPSDT and MCH Regional Coordinator
214-767-6301
214-767-6497
Region VII
Iowa, Kansas, Missouri, Nebraska
Kansas City Regional Office
Richard Bolling Federal Building
601 East 12th Street
Kansas City, MO 64106-2808
Medicaid Associate Regional Administrator
EPSDT and MCH Regional Coordinator
816-426-5925
816-426-3406
Region VIII
Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming
Denver Regional Office
Health Care Finance Administration
Division of Medicaid and State Operations
1600 Broadway, Suite 700
Denver, CO 80202
Medicaid Associate Regional Administrator
303-844-1977
EPSDT and MCH Regional Coordinator
303-844-2682
52
APPENDIX C
U.S. Department of Health and Human Services
Regional Contacts
Region IX
American Samoa, Arizona, CNMI, Guam, California, Hawaii, Nevada
San Francisco Regional Office
75 Hawthorne Street
San Francisco, CA 94105-3901
Medicaid Associate Regional Administrator
415-744-3568
EPSDT Regional Coordinator
415-744-3596
Regional MCH Program Consultant
Federal Office Building
50 United Nations Plaza
San Francisco, CA 94102
415-744-3553
Region X
Alaska, Idaho, Oregon, Washington,
Seattle Regional Office
2201 Sixth Avenue
Seattle, WA 98121-2500
Medicaid Associate Regional Administrator
EPSDT and MCH Regional Coordinator
206-615-2313
206-615-2343
53
APPENDIX D
Voluntary and Professional
Health Organizations
American Academy of Allergy,
Asthma, and Immunology
1-800-822-2762
www.aaaai.org
Cleft Palate Foundation
1-800-24-CLEFT
www.cleft.com
American Academy of Pediatrics
1-847-434-4000 (National
Headquarters)
www.aap.org
Easter Seals
312-726-6200 (voice)
312-726-4258 (TTY)
www.easter-seals.org
American Cancer Society
1-800-ACS-2345
www.cancer.org
Epilepsy Foundation of America
1-800-EFA-1000
www.efa.org
American Diabetes Association
1-800-DIABETES
www.diabetes.org
Food Allergy & Anaphylaxis Network,
Inc.
1-800-929-4040
www.foodallergy.org
American Heart Association
1-800-AHA-USA1
www.americanheart.org
Muscular Dystrophy Association of
America
1-800-572-1717
www.mdausa.org
Arthritis Foundation
1-800-283-7800
www.arthritis. org
Association for Retarded Citizens
(The ARC)
National Headquarters
301-565-3842
www.thearc.org
Autism Society of America
1-800-3-AUTISM
www.autism-society.org
Crohn’s and Colitis Foundation
of America, Inc.
1-800-343-3637
www.ccfa.org
National Cystic Fibrosis Foundation
1-800-FIGHT CF
www.cff.org
Spina Bifida Association
of America
1-800-621-3141
www.sbaa.org
United Cerebral Palsy Association
1-800-USA5-UCP
(TTY)202-973-7197
www.ucpa.org
54